Kimberly Marselas

Last week, the Centers for Medicare & Medicaid Services put out a request for feedback on the Medicare Advantage program, which is rapidly becoming the nation’s preferred healthcare insurer provider for seniors.

Until they really need coverage, that is.

About this time last year, the Government Accountability Office reported that MA beneficiaries in the last year of life disenrolled to join (or return to) Medicare fee-for-service at more than twice the rate of all other MA beneficiaries. The watchdog suggested that this disproportionate disenrollment “may indicate potential issues with their care,” especially because plans may not cover specialty services, skilled nursing or home health care needed near the end of life.

Enrolles whose health is rapidly declining may also — not surprisingly —  need more services than healthier or younger beneficiaries. But the GAO found MA plan’s routine  practices, including prior authorization, may make it hard enough to access care that patients choose a new insurer.

Still, even as the number of patients jumping ship increases, the number of overall enrollees keeps increasing.

It’s hard to see past how cheap MA plans appear from the surface, and in fact, they’re getting even cheaper to join. CMS last year put the average monthly plan premium for all enrollees in 2022 at $19 a month, continuing a five-year pattern of declines.

Many old enough to sign up for coverage see that low up-front expense and bonus benefits like provided meals and covered vision and dental exams as major advantages.

What they don’t see in the murky provider pool below is that costs may escalate quickly when they need serious care. A 2021 Kaiser Family Foundation analysis found more than half of MA enrollees have higher costs than traditional Medicare patients when facing a six-day or longer hospital stay.

And you can’t forget just how confusing all of this can be. In some areas, beneficiaries can choose from as many as 65 plans! I don’t care how retired I may be 20 years from now; I will never have enough free time or energy to compare that many coverage options. 

Predicting which care will be covered under any plan also can feel like a very bad joke. See above, and then see below. 

In late April, a sample study by the Office of Inspector General found Medicare Advantage organizations too often delayed or denied beneficiaries’ access to services, even though the requests met Medicare coverage rules. Post-acute facilities were among those most often involved in erroneous denials, with 13% of denied prior authorization requests meeting Medicare coverage rules, as well as 18% of denied payments.

We already know the pattern is pervasive enough that skilled nursing providers have stopped working with certain MA plans; others have grown their billing offices to try and recoup what they deserve for care delivered.

Until now, no one at CMS has publicly agreed to do more than monitor some of these issues. That could be changing. Maybe.

Last week, in near lockstep with the CMS request for comment, a key House panel advanced legislation to reform the Medicare Advantage prior authorization process. The bill would force  MA plans to report to CMS how often they use prior authorization and their denial rates.

It has more than 300 sponsors. In a Congress that can’t agree on much of anything, I’d say that’s a pretty solid public comment that something about the current MA billing process is badly broken.

If CMS truly wants to make MA more advantageous, it must do so for patients and healthcare providers alike. It’s time to take the reams of already-available criticism from federal watchdogs, weary nursing home operators and jilted beneficiaries, add those to the stack of comments that are about to pour in, and change the tide for the better. 

Kimberly Marselas is McKnight’s Senior Editor.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.